Early pregnancy disorders currently account for approximately three-quarters of emergency gynaecological admissions
and are an important cause of maternal morbidity and mortality throughout the world.
Disorders of early pregnancy:

The classical symptoms triad for early pregnancy disorders is :
1. amenorrhoea.
2. pelvic or low abdominal pain.
3. vaginal bleeding.
Pregnancy symptoms are often non-specific and many women of reproductive age have irregular menstrual cycles. Symptomatology

Human chorionic gonadotrophin has a half-life of 6-24 hours and rises to a peak in pregnancy at 9-11 weeks' gestation.
Pregnancy tests
The first test to confirm the existence of pregnancy is for the detection of human chorionic gonadotrophin (hCG) in the patient's urine or plasma

Human chorionic gonadotrophin is a placental derived glycoprotein, composed of two subunits, alpha and beta, which maintains the corpus luteum for the first 7 weeks of gestation.
Extremely small quantities of hCG are produced by the pituitary gland and thus plasma hCG is almost exclusively produced by the placenta. Pregnancy tests

An ectopic pregnancy occurs when the conceptus implants either outside the uterus (Fallopian tube, ovary or abdominal cavity) or in an abnormal position within the uterus (cornua, cervix).
Combined tubal and uterine (heterotopic) pregnancies are uncommon.
Definition:

Site of tubal ectopic pregnancy are:
1.More than 50 % of tubal pregnancies are situated in the ampulla.
2. approximately 20 % occur in the isthmus.
3. around 12 % are fimbrial .
4.approximately 10 % are interstitial
Site of ectopic pregnancy:

any mechanical or functional factors that prevent or interfere with the passage of the fertilized egg to the uterine cavity may be aetiological factors for an ectopic pregnancy.
Functional Factors : are
1.pregesteron only pill.
2. Intra uterine device.
3. Luteal phase defects
4.Cigarette smoking
5.Vaginal douching
Ectopic pregnancy: pathophysiology

pathophysiology -It is believed that the main cause for a tubal implantation of the gestational sac is a low-grade infection,
as approximately 50 % of women operated on for an ectopic pregnancy have evidence of chronic pelvic inflammatory disease.

A high proportion of women with a tubal pregnancy miscarry during the early stages of gestation.
The products of conception may persist for a considerable period of time within the tube as one form of 'chronic ectopic pregnancy', or they may be gradually absorbed.
pathophysiology

pathophysiology If implantation occurs into a site of the tube that offers a sufficient area for placentation, the process is very similar to that of an intrauterine pregnancy,
for the conceptus penetrates the tubal mucosa and becomes embedded in the tissues of the tubal wall.

The extravillous trophoblast will penetrate the full thickness of the muscular layer of the tube to reach the subserosa and the tubo-ovarian circulation.
Due to its limited distensibility, the tube will rupture and usually accompanied by fetal death,
occasionally following rupture the fetus retains sufficient attachment to its blood supply to maintain viability and secondary abdominal pregnancy can proceed to term.
pathophysiology

In an ectopic pregnancy, the uterine endometrium usually responds to the hormonal changes of pregnancy and undergoes focal decidua changes (Arias-Stella reaction).
If the ectopic pregnancy miscarries, the uterine decidua may slough off as a cast, but more commonly as fragments mixed with small blood clots.
pathophysiology

:Uterine Changes in Ectopic Pregnancy The uterus undergoes some of the changes associated with early normal pregnancy, including increase in size and softening of the cervix and isthmus.
Lack of uterine changes does not exclude an ectopic pregnancy.

Compared to the other forms of early pregnancy disorders, there is no pathognomonic pain or findings on clinical examination that are diagnostic of a developing extrauterine pregnancy.
Vaginal bleeding (usually old blood in small amounts) and chronic pelvic pain (iliac fossa, sometimes bilateral) are the most commonly reported symptoms.
Clinical features

Signs & Symptoms 4. Uterine changes
In 25% of women, the uterus enlarges due to hormonal stimulation of pregnancy.
5. Blood pressure and pulse
Before rupture vital signs are generally normal. Hypotension and tachycardia – if bleeding continues and hypovolemia becomes significant
6. Pelvic Mass
Almost always either posterior or lateral to the uterus, and typically soft and elastic
The mass may be firm with extensive infiltration of blood into the tubal wall.

This must include a record of pulse rate and blood pressure.
Shoulder pain, which may occur secondary to blood irritating the diaphragm .
vascular instability characterized by low blood pressure, fainting, dizziness and rapid heart rate may be noted.
These symptoms are present in more than 50 % of patients and are most typical of patients whose ectopic pregnancy has ruptured (intra-abdominal bleeding).
General examination

Speculum or bimanual examination must be performed in an environment where facilities for resuscitation are available,
as this examination may provoke the rupture of the tube.
Gynaecological examination:

Culdocentesis: to exclude haemoperitoneum has also been a routine investigation in the emergency room to rule out ectopic pregnancy.
Because this test is based on late development in the natural history of the ectopic pregnancy, it is obviously not going to be useful in detecting an early ectopic pregnancy.
Culdocentesis

Culdocentesis
The cervix is pulled toward the symphysis with a tenaculum, and a long 16- or 18-gauge needle is inserted through the posterior fornix into the cul-de-sac
Fluid containing fragments of old clots, or bloody fluid that does not clot, is compatible with the diagnosis of hemoperitoneum resulting from an ectopic pregnancy

plasma hCG and transvaginal sonography have allowed for a less invasive evaluation of the patient with a suspected ectopic pregnancy.
The hCG levels and ultrasound findings must be interpreted together.
One of the most important parameters is the discriminatory hCG level above which the gestational sac of an intrauterine pregnancy should be detectable by ultrasonography (usually l000 -1500 IU/L).
Human chorionic gonadotrophin and transvaginal ultrasound:

The presence or absence of an intrauterine gestational sac is the principal point of distinction between intrauterine and tubal pregnancy.
The sonographic finding of an extrauterine sac with an embryo or embryonic remnants is the most reliable diagnosis of ectopic pregnancy.
An empty ectopic sac or a heterogeneous adnexal mass is a more common ultrasound feature.
ultrasound

The presence of fluid in the pouch of Douglas is a non-specific sign of ectopic pregnancy.
In 10-20 % of ectopic pregnancies, a pseudogestational sac is seen as a small, centrally located endometrial fluid collection surrounded by a single echogenic rim of endometrial tissue undergoing decidual reaction.
ultrasound

Surgical Management: CONSERVATIVE Salpingostomy
Used to remove a small pregnancy usually <2 cm in length.
A 10-15 mm linear incision is made on the antimesenteric border immediately over the ectopic pregnancy, and is left unsutured to heal by secondary intention
Readily performed through a laparoscope
Gold standard surgical method used for unruptured ectopic pregnancy

The classical approach to the treatment of ectopic pregnancy has always been surgical:
(salpingectomy or salpingotomy),
either by laparotomy or laparoscopy.
the wider use of ultrasound, an early diagnosis is now possible in many cases before the onset of symptoms.
Management

Medical Management: METHOTREXATE An anti-neoplastic drug that acts as a folic acid antagonist, and is highly effective against rapidly proliferating trophoblasts.
Success is greatest if
The gestation is <6 weeks
The tubal mass should be <3.5 cm in diameter
The fetus is dead
Β-hCG is <15,000 mIU/mL

Non-surgical (medical) therapeutic approaches have been introduced, such as
puncture and aspiration of the ectopic sac,
local injections of prostaglandins.
potassium chloride.
hyperosmolar glucose .
methotrexate.
The advantages of treatment that does not involve surgery or the use of potentially toxic drugs are obvious.
Management

With earlier diagnosis it has also become apparent that spontaneous regression of tubal pregnancies is more common than previously thought.
This has led to non- interventional expectant management, which is based on the assumption that a significant proportion of all tubal pregnancies will resolve without any treatment.
Management

Unfortunately, not all patients will be suitable for this type of treatment or for a simple follow-up, and strict criteria must be observed in the selection of patients.
Ultrasound examinations combined with serial hCG assessments are prerequisites for successful expectant management or in the follow-up of the patient treated medically.
Management